Too many people show up to be seen by medical professionals at similar times. This creates bottleneck: more customers than gurneys on which to park them; many more patients than doctors and nurses (and PAs–physician assistants–a growing cadre of medical professionals in the U.S.)

ERs are the beneficiaries (a mixed blessing, to be sure) of a clear and simple message: “We’re always open. You can always be seen, regardless of ability to pay.” The bargain is that you have to be willing to wait. For thousands of people, perhaps millions, it’s a reasonable bargain. At least when they enter it is. Sometimes the waits are interminable.

Many people wind up leaving without being seen, unsatisfied by sitting so long. On the one hand, ER management wants to send the message: if you’re low priority (your issue is not a true emergency), you’re going to wait. And wait.

And wait.

On the other hand, ER management doesn’t want the LWBS (left without being seen) percentage to get too high. It’s a mark of poor quality in the ER world. If your light is on but a significant percentage of your patients are leaving without ever being evaluated, then you can’t say that you’re doing such a good job.

ER tacticians are always dreaming up ways of improving this situation.

A smattering of sample ideas:

1. Discourage ER use for non-emergency, non-urgent conditions.

2. Encourage people to choose a “medical home” in their community and build a relationship with that home so that when needs arise, they can be handled in a timely manner.

3. Create parallel tracks, like “Fast Track,” that skim off the easy to treat complaints–the sore throats, the mild upper respiratory infections, and ‘treat ’em and street ’em” quickly, so as to avoid overcrowding.

Problems with those sample ideas:

1. This clearly hasn’t worked. Also, broadcasting this message has an implicit snobbishness–as in “We don’t think your problem is serious–you’re just crowding us.” This message also runs counter to the great simplicity of the ER brand of “we’re always open, you can always be seen.”

2. The jury is still out, but the shortage of primary care homes (and primary care doctors) has made this a real challenge–and judging by the current crowding, doesn’t seem like this message is gaining general acceptance.

3. “Fast Tracks” run counter to idea #1. My own hospital’s ER ended its Fast Track since it just encouraged ER use for non-urgent conditions–and in one sense rewarded those seekers by giving them fast, timely care. The really sick people still had to wait in the general waiting room (albeit not as long as they otherwise might have, but a long time nonetheless).

Keep in mind of course, that all of this depends on who is defining the condition as urgent or not. To the patient, of course it’s urgent. Why else would they take the time to show up?

I’m a primary care doctor. I’m troubled when my patients use the ER for reasons that could easily be seen or evaluated in my office. Of course, if the situation calls for it, or the patient prefers it, I’m glad the ER option is available as an option.

But there’s a reason so many people turn to the ER when they want to see a doctor. They may get chastised for using the ER when it’s not an emergency, but the promise of getting seen when they want to be seen is simply too alluring.

No fussing with appointments. No being put off for an opening in the schedule or showing up at an office when it’s convenient for the doctor’s schedule. In the ER, the light is always on, and at least somebody’s home.

My office closes at 5pm. We have limited weekend hours. This works well for me and my family life, but it’s often not convenient for the patients that I see.

[Since I work in a large group practice, I have less individual autonomy to set my own hours and practice schedule.)

Under managed care plans (rmember HMOs?), ER use is restricted or at least dissuaded by a co-pay, deductible, or needing advance permission from the primary care doctor (or at least the office).

The litany against ER overuse includes many of the following:

-Too many non-emergencies cloud the ability of the facility to handle real emergencies.
-The ER should not be used as a medical home.
-The ER is not a setting in which preventive care can be offered.

This is not a problem that will soon be solved.

Health care reform, when it passes, won’t be enacted for three years. And without changing the incentive structure (i.e. relative earning potential) for medical school graduates, we will continue to produce a dearth of American-born, American-trained primary care physicians.

4 Comments

As a patient, I find myself stuck. If I call my PCP and report a problem urgent enough that it is disrupting my normal daily life, function and sleep, I have been met with the response that I can get an appointment in 4-6 weeks!! (One exception was a breast lump – saw me the next morning; another was great difficulty breathing and chest pain due to a bad fall — saw me in hours, turned out to be just cracked ribs and muscle pain.)

Timely treatment of very painful or worrisome conditions is unlikely. At one point, during a yearly physical, my doc asked about x, y and z. I said that Z had been really painful. When did that start? My answer of it’s been going on for weeks puzzled him — why didn’t you call me? Because your office wanted to give me an appointment six weeks from now and if that wasn’t okay, they told me to take myself to an ER.

So, being a stoic, and unwilling to risk the insurance company refusing a trip to the ER that they might not view as an emergency, I often just suffer, swallow a lot of ibuprofen, do palliative care and get through.

At such times, I just act like I live on the far reaches of the tundra or somewhere far from medical help. If there was substantial bleeding, pain I couldn’t moderate somewhat, broken parts or obvious problems, I’d head to the ER. But otherwise, no… not the ER, nor to the doctor’s.

Having said all that, nearly all of my ER experiences to date (many due to being involved with horses!) have been good ones. Not all – there was the severe concussion (blacked out for 2-3 minutes, did not know my name, address, the date, etc.) where the ER staff parked me on a bed, and left me there for 2 hours — and yep, I surely did fall asleep but good. Glad I woke up!

I understand that the doctors and nurses and hospitals are all laboring under a very difficult system. I hope in my lifetime things change. People come from all over the world to learn from the very best here in the US, and yet, the US citizen can’t always benefit from so much that is available.

I think we need something on the order of a “customer service” revolution in health care. We providers in general don’t concern ourselves enough with patient satisfaction, or put ourselves in your shoes enough.

So, you go home at 5PM and the baby develops an ear ache at 10PM and is screaming…or…mama gets a migraine and can’t function….or…sis gets a bladder infection that goes nuts on Sunday at 10AM…or…your neighbor has a rattling chest on Friday at 7PM and you are not sure it is pneumonia or just a chest infection… Where do we go? Not all of these things can kill you, but why do we have to suffer for hours or even days because the social norm is 8 to 5 M-F for doctors to keep their office hours? Why can’t doctors be like high tech workers or cops or firemen and have shifts? Not everyone, including doctors, is a morning person. I’d wager some would be even more effective if they could work during the hours when they are personally most effective.

As a physician in primary care, too many patients think we get compensated (paid) for any question or form done or for any advice given. Unfortunatly the insurance industry has made primary care a fee for service industry. If I don’t see the patient, I won’t get paid.

Would patients be willing to pay extra for all the behind the scenes services they expect? How about the insurance companies giving the physician a monthly stipend to cover these services patients expect?